Monthly Archives: December 2012

Post navigation

Yesterday’s post on CorVel was cut short by the demands of real work; here’s the rest.

Financially, CorVel has had a very mediocre year. Their most recent quarter saw revenues stay pretty much flat, while earnings dropped 10 cents a share from 68 cents the previous quarter; the last six months saw a decline of the same magnitude. Revenues increased less than a million dollars for the latest quarter, while “cost of revenues: was up about $4 million. The company attributed that increase to the higher cost of running their TPA operations, which are more labor-intensive than managed care ops, and higher costs for drugs.

Their latest push appears to be in pharmacy, where they’ve been touting MedCheck’s ability to control costs more effectively than PBMs (disclosure – I work with a number of PBMs thru CompPharma).

Here’s how their most recent press release put it:

CorVel is uniquely positioned in the marketplace to more effectively manage pharmacy costs due to the Company’s integration with its bill review solution. MedCheck?, the Company’s medical bill review software, captures all prescription out of network transactions such as the rising occurrence of physician dispensing. These transactions are generally not managed via pharmacy benefit management (PBM) programs, which traditionally only track point of sale (POS) prescription purchases.

Sounds good, except it’s wrong.

In fact, most PBMs do capture prescriptions from third party billers, mail order, paper bills; a majority see bills from physicians as well (over half, according to the latest data on the subject).

Notably, CorVel’s “PBM” uses one of the huge group health/Medicare PBMs’ pharmacy contracts. While this can drive great discounts, network penetration (the percentage of scripts that actually go thru the network) is often an issue. (basing this on data I’ve seen from several payers that have used different PBMs). Thus, they can deliver great rates but for a relatively smaller number of scripts.

Finally, management.

Founder Gordon Clemons Sr is listed as CEO, a position he has held since Dan Starck’s departure earlier this year. Clemons’ son, Victor Gordon Jr., was rumored to be tagged to take over for Senior, however that apparently didn’t work out; Jr. resigned a couple months ago to “pursue personal interests.”

The company is decentralized, with regional execs essentially running regional businesses. There’s a good deal of autonomy, and some offices are quite good while others are not. The challenge comes in working with national payers who want consistency; that’s tough for any decentralized operation. Their sweet spot is mid-tier and smaller regional payers, although they do work with at least one national insurer.

The foray into the TPA world has reportedly had mixed results; CorVel’s been able to add business, while losing managed care business from TPAs that now consider – rightly so – CorVel to be a competitor.

As the work comp insurance market hardens, there will be more opportunities for TPAs as employers seek lower costs from self-insurance. However, buyers are getting more savvy as well, and CorVel’s going to have to be aware of this dynamic; employers are increasingly aware that TPAs make up for low claims fees by increasing revenues from managed care services.

It’s been a while since we last looked in to see what’s going on at the managed care company/TPA. Back in May, CEO Dan Starck left to go back to his previous employer, leaving a hole at the top.

Senior staff welcomed former CEO Gordon Clemons senior back, but Gordon junior was rumored to be in the running for the top slot. Word is senior management wasn’t all that excited. More to come…

Financials for the most recent quarter are not great: revenues are essentially flat and earnings down 10 cents per share from 68 cents the prior quarter.

CorVel has been operating as a TPA and managed care firm for several years now. While I don’t have access to any data on their TPA performance, there is data available on their managed care results.

Fortunately, the good folk at Texas Division of Workers’ Comp provide an evaluation of the networks operating in the Lone Star State; CorVel’s is included. The news is not so good. CorVel’s network performance in Texas is, well, poor relative to the competition. With average medical cost per claim almost 10 percent higher than the next most costly HCN, CorVel’s customers have the highest medical cost per claim of any HCN in the study. Other data points of note:

37 percent of injured employees reported problems accessing care, second lowest among all HCNs in the study.

12 percent of injured employees reported they had not returned to work, second worst in the study.

It is possible CorVel’s client base has greater risks and more severe injuries. The 2011 report indicatedCorVel had the highest rate of lost time claims of all networks – a whopping 42% of all claims were lost time…

I was talking to an insurance company claims exec about CorVel; this was her/his take: “We have always been concerned about them from an ALAE [allocated loss adjustment expense] standpoint. They only started the TPA business because the other TPAs were taking all their other bill review and case management business away.

Unfortunately, they are not alone when it comes to TPAs who put greater emphasis on ALAE billing than claims handling. It’s a plague of the industry right now.”

As I’ve noted in the past, this is partially the responsibility of employers. They’ve been able to beat up TPAs for ever-lower administrative fees to the point that some TPAs were losing money on claims handling. As TPAs seem to remain solvent, many have looked to increase charges for managed care services, and perhaps CorVel is one that has followed this route.

Workers comp payers around the country are seeing their bills – and payments – for inpatient and outpatient services increase significantly faster than other costs.

And all indications are those increases are going to…increase.

The latest WCRI reports (kudos to Rick Victor et al for getting ever-more current data into their studies) show facility costs are up substantially in several states. Indiana’s facility costs were substantially higher than WCRI’s median states, driven by prices. As Indiana doesn’t have a fee schedule for facilities, hospitals can jack up prices whenever they want - and they are.

When – not if – those cuts are announced, we can expect facility costs to increase. In states like Indiana where there is no fee schedule, those increases will be driven by a combinaton of higher prices and more services per episode.

In fee schedule states, watch for significant increases in utilization – more and higher-intensity services per stay.

Sure, they’re hiding behind grand words such as “patient choice” and “return to work”, but those are just code words for “we’ll sock taxpayers and employers for as much as we can as long as we can, and to hell with ethics.”

The president of the FMA, one Miguel Machado, said last year “encouraging patients to comply with prescriptions ensures that they will get back to work sooner.” His legislative lead said:

“The FMA maintains that physician dispensing of medications is one of the most effective means of patient compliance, which means injured workers can return to their jobs sooner.”

There are two issues here; one is the FMA’s inability to support that statement with any research, and two; the fact that physician dispensing is outright dangerous.

Truth is there is not one shred of evidence that dispensing drugs results in faster return to work or better outcomes. There is NO DATA, no research, no information, no studies, no indication whatsoever that physician dispensing does anything positive; unless you count enriching doctors, repackaging companies, and the firms that enable those practices as positives…

And let’s not forget it enriches investors, specifically ABRY Partners, that own physician dispensing companies. And yes, that’s the same ABRY that also owns TPA York Claims and MSA firm Gould and Lamb. (Nothing against York, mind you – the people I know there are very good and very committed to doing the right thing for their customers)

There is a plethora of evidence indicating that ending outrageous profiteering on physician dispensed drugs does NOT end the practice of physician dispensing, but it seems Machado’s medical degree did not come with even a basic understanding of science or statistics. If it did, he would be able to read WCRI’s report on California which showed no significant decrease in physician dispensing after CA tied the price of repackaged physician dispensed drugs to the original manufacturer’s price.

The second issue is even more troubling.

Machado’s doctors don’t have access to pharmacy databases that retail stores use to prevent potentially deadly drug interactions. Pharmacists in retail stores are required to check computerized databases to ensure the drugs they are dispensing don’t conflict with other medications their patients are taking. There’s no such requirement for Machado’s doctors. And, because most work comp claimants are seen by docs who haven’t seen the patient before, the treating physician doesn’t have a complete medical record – or access to one.

I don’t know what it will take to convince these hypocrites of the error of their ways; perhaps news of the first – or second, or third – patient death caused by a fatal drug interaction from a physician-dispensed drug. It is horrible indeed to consider, but when one remembers Florida is the same state that refuses to fund its prescription drug monitoring program and waited years before closing pill mills, it may well take multiple deaths before the FMA does the right thing.

Kudos to Sen Alan Hays, DMD for his principled and active commitment to fixing this problem.

If you want to let the FMA know your thoughts on this, their number is 800-762-0233; even better, their twitter handle is @FloridaMedical.

Of course, it’s up to you, but you may want to tweet something like “@FloridaMedical’s drug dispensing position puts #ProfitsBeforePatients”.

That said, if we don’t get a resolution by mid-January, the proverbial stuff will hit the fan.

So two scenarios.

One, it gets fixed over the next month. Some delay in premium payments from governmental entities. Perhaps a holdup on changes to Medicare physician reimbursement and docs hold bills in hopes their reimbursement doesn’t get slashed. Some employers will hold off on hiring while they wait for the kids in the sandbox to get their $%&(@% together. And delays in starting infrastructure work or continuing existing projects will undoubtedly occur…

That’s about it.

Which leads us to the “oh crap” scenario, the one where DC pols decide to cross the stupid line.

Government spending on infrastructure would all but cease; employers would stop hiring and might well lay off workers; health care providers – especially hospitals – would likely cut staff as well; manufacturing would slow appreciably, state, local, and municipal governments would furlough employees…

You get the picture. As a result, comp premiums would drop significantly, few employers would look to switch insurers or administrators, and service providers/vendors would likely see a significant decrease in business as well.

So, let’s not go there.

I fully expect our elected officials will fix this before it’s too late. The political consequences (are there any other?) would be catastrophic if they don’t.

As Winston Churchill said of us: “The Americans will always do the right thing… after they’ve exhausted all the alternatives.”

There’s an easy $200 billion in deficit reduction out there – require CMS to negotiate drug prices with manufacturers, a move that would reduce annual expenditures by over $20 billion – or $200 billion closer to a “cliff”-avoiding deal.

The cost to taxpayers for Part D in 2011 was $53 billion; over the next ten years, our cost will balloon to $990 billion.

Of course, we could solve the majority of our budget problems by just canceling Part D, but neither the Democrats nor the Republicans will do that.

So, as long as we’re stuck with the damn thing, we ought to make it as inexpensive as possible. The best way to do that is to use the buying power of Part D to negotiate with manufacturers to get the best possible price for drugs that you – the taxpayer – are paying for. Believe it or not, the original Part D legislation expressly forbids negotiation with manufacturers for pricing.

In a 2006 House analysis, a report “showed that under the new Medicare plan, prices for 10 commonly prescribed drugs were 80% higher than those negotiated by the Veterans Department [emphasis added], 60% above that paid by Canadian consumers and still 3% higher than volume pharmacies such as Costco and Drugstore.com.”
Another study indicated “An annual savings of over $20 billion could be realized if FSS [Federal Supply Schedule] prices could be achieved by the federal government for the majority of drugs used by seniors in 2003-2004…”
Are there problems with this? Absolutely. Reducing prices may impact R&D expenditures and will affect pharma margins – effects that must be balanced against the nation’s long-term financial viability.

Notably, the President’s public statements on the negotiations haven’t mentioned the long term costs of Part D either. It is puzzling indeed that President Obama has not publicly put this chip on the table. Perhaps it’s because pharma has already “contributed” to paying for health reform with their $80 billion in

That said, Speaker Boehner’s the real hypocrite here. The Orange One could have been courageous – admitting he and his party made a mistake in refusing to allow CMS to negotiate with pharma, and thereby saving taxpayers $200 billion over the next ten years. Sure, he would’ve taken a hit from older Americans who love Part D, but true statesmen, real leaders, know that tough, unpopular stands are necessary some times.

Like now.

What should we do?

Either a) end Part D or

b) allow the Feds to use their buying power to negotiate with pharma. That alone would save about $20 billion a year.

Canceling Part D won’t happen; neither party is about to tell seniors they can’t have free medicine. If Boehner, McConnell, Tea Party Congresspeople- and the Administration – were really concerned about the deficit, they’d agree to use the government’s buying power to reduce costs and thus lower the deficit. But of course they won’t; that would alienate big pharma and cut into their campaign contributions.

The latest report from WCRI shows medical costs in Indiana have been rising rapidly over the last few years, driven by facility cost increases. This comes as no surprise, as facilities’ increasing leverage and ability to raise prices has been affecting comp in many states.

This comes on the heels of a similar report on Virginia and news of a significant rate jump in New Jersey, in large part due to increased medical trend.

Rates are up in the Sunshine State too, and yes, higher medical costs – facility and repackaged drugs – are the driver.

Over the last few years, medical inflation, as reported by NCCI has been pretty much under control. It certainly looks as if those days are over.

What does this mean for you?

Time to dust off those medical management programs – and update them as well. Because what worked back in the day will likely not work now. If it did, you wouldn’t see these cost increases.